HomeMy WebLinkAboutBuilding Permit #341-14 - 276 MASSACHUSETTS AVENUE 10/9/2013 TOWN OF NORTH ANDOVER
r PLICATION FOR PLAN EXAMINATION
Permit N0: l Date Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page
OCA
PROPERTY OWNER_
� Print 100 Year Old Structure yes no
MAP,NOifPARCE_ LZONING DISTRICT: _ _ Historic District ye no
e Machine Shop Village ye _ no
� . . -
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building 2-One family
❑Addition ❑ Two or more family ❑ Industrial
Iteration No. of units: ❑ Commercial
9 Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well, ❑ Floodplain ❑Wetlands ❑ Watershed_ District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: � —� Phone: gT�'�¢" �'g
Add ress: VO Mk�� 4V tS—, ,
,CONTRACTOR Name: A�N +WPeN Phone:
a
Address: V� � c � t�� N �1/l l r �►
Supervisor's_ Construction License: -_:Exp: pate:
Home Improvement License: 171 C60 _ _ _ Exp. Date: 7�AN I�
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.0 R$1000.00 OF THE TOTAL ESTIMATED COST B�D ON$ 25.00 PER S.F.
Total Project Cost: $ FEE: $
a
Check No.: Receipt No.:
NOTE: Persons con g withunre is red contractors do not have access to the guaranty fun
gnature of Agent/Ow_ne ature.of cont_ractor�� T �
Plans Submitted F Plans Waived ❑ Certified Plot Plan ❑ St�m ed Pla /s V
p
Building Department
The foll,oOwing is-fa.list of the required forms to be filled out for the appropriate.permit to be obtained.
Roofivg, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑
Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apt),-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Buil,ding Permit Revised 2012 .
Plans Submitted PlansWaived-11 Certified Plot Plan ❑ Stamped Plans ❑
TYPE_OF-:SEWERAGE.DiSPOSAL
Public Sewer Ff Tanning/Massage/Body Art ❑. . Swimming Pools ❑
Well ❑ Tobacco.Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE.APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
-CONSERVATION Reviewed on Signature
COMMENTS
j HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Tow;2 Engineer: Signature:
- _ Located 384 Osgood Street
FIRE DEP' '
RTML-,NT - Temp Dumpster on site yes no
Located at 124,Mair Street
Fire Department signature/date`' t
COMMENTS �' -
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions. 1 �
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine
NOTES and DATA— (For department use
E3 Notified for pickup - Date
E
Doc.Building Permit Revised 2010
Location
No. Date/v c;k? ^
d
e - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
'
Building/Frame Permit Fee $ "
Foundation Permit Fee $
`V.! ,3CN#YIF14Hk � 1�
Other Permit Fee $
TOTAL $
Check#
26 . Y 9
Building Inspector
Enter construction cost for fee cal - North Andover Fee Caku/ation
Construction Cost
42,000.00 m
$ - $ 504.00
Plumbing Fee $ 63.00
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 63.00
Total fees collected $ 730.00
276 Mass Avenue
341-14 on 10/9/2013
Kitchen Remodel
NORTH
own of _ Andover
I- .
No. T
hver, Mass 6k
A CoCMICNI W#CN *_1'
I.q AERATED P C>
S u
BOARD OF HEALTH
Food/Kitchen
PET T LD Septic System
THIS CERTIFIES THAT ....... ............................... BUILDING INSPECTOR
Foundation
has permission to erect . .. buildings onJ �'M 00
..... ................ .. . ......... .... ..... ... . .. ... ..... ........... g
g Rough
to be occupied as .......k 4c.�.%!!w........ .". 444.)........................................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
01
UNLESS CONST RTS Rough
Service
.... .. ....... ............................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
SEE REVERSE SIDE
The Commonwealth of Massachusetts -
Department of IndustrialAccidints
Office of Investigations
600 Washington Street
Boston,MA.02111
www.massgov/dza
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/individual): `�N AA`I Dei V
Address: -
City/State/Zip: � Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
,employees(full and/or part-time).` have hired the sub-contractors
2.® I am a sole proprietor or partner- listed on the attached sheet. �• E]Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. . 9, []Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10,❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp, c. 152,§1(4),and we have no 12.❑Roofrepairs
insurance required.]t employees.[No workers' 13.❑Other
comp.insurance required.]
'Any applicant that checks box#f must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they fire doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:.
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL o.152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one=year imprisonment,as well-as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
'Investigations of the DIA for insurance coverage verification.
I do hereby certKy under the ' s an pen�lli`ies ofperjury that the information providebove is true and correct. -
Signature: / Dater ?
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other - -
Phone#:
Information and Instructions
io
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,-
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein or the occupant ant of the
p
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced-acceptable evidence of compliance with the insurance coverage re required."
Pq ,
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are notiequ'uedto carry
compensation in
surance. If an LLC or LLP does s have
employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the' application for the permit or license i
s being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if are ou required to obtain a workers'
Y
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate nate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only.submit one affidavit indicating current
Policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number: j
The Coir mmwealth ofM-ossarh-.segs
DepartYxzent off dustrial.Accidents
Office oflayesti,gatimm
600-Washuzgtoa Street
Boston,MA 02111
Teel,#617-727-4900 ext 406 or 1.-877:MA.SSAFB
Revised 5-26-05 Fax#617-727-7749
Jason S. Hayden, General Contractor
5 Gunstock Drive
Kingston, NH 03848
Jhayden1213@yahoo.com
(978)697-6362
QUOTATION
October 7, 2013
TO: Deb Lord and Claire O'Brien
276 Mass Ave North Andover
978-204-1836
TERMS: Down payment of 1/3 due before project start date All other payments to be
scheduled per payment schedule.
DELIVERY: Estimated 3 -4 weeks to complete
FOB: North Andover, MA
OVERVIEW: Kitchen Remodel
ITEM I DESCRIPTION COST
Project Summary:
Kitchen remodel
1 Existing Slab: NIA
2 Floor:
To Be determined
3 Walls:
Wall studs are 2" x 4" KD lumber, new 2"x 8" header at window, install pocket
door framing kit, install blocking where needed for kitchen cabinet install
4 Insulation:
1. R-13 in walls
5 Roof: N/A
6 Interior walls:
Install sheetrock, and 3 coats of skimcoat per(4]walls. Existing ceiling to remain.
MA Supervisor's Construction License#78189
MA Home Improvement Contractor License#149663
Jason S. Hayden, General Contractor
5 Gunstock Drive
Kingston, NH 03848
Jhayden1213@yahoo.com
(978)697-6362
7 Doors:
Install door slab in pocket door frame
8 Windows:
Install new casement window per customer order
9 Interior trim:
Install new interior trim on window in pocket door. Install baseboard trim
10 Wood flooring:
N/A
11 Tile floor:
N/A
12 Cabinets:
Receive and Install kitchen cabinets, associated hardware and accessories
13 Bathroom accessories:
N/A
14 Appliances:
Install refrigerator, dish washer, microwave, stove
15 Siding:
Install siding where applicable; at window area
I
16 Roof Trim:
N/A
17 Egress Landing:
N/A
Note 1 Also included:
Building Permit, dumpster
Note 2 Not included:
Electrical and Plumbing supplied by homeowner
HVAC mechanical to be retrofitted by General contractor
Painting
Note 3 All changes to project must be made in writing:
TOTAL $8,700
MA Supervisor's Construction License#78189
MA Home Improvement Contractor License#149663
ACOIRVCERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
6/24/2013
TH$(CERTIF ICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(iss)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement_ A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER CONTACT
NAME. Lauren Goldman
Cross Insurance-Peabody PHONE 1978)532_5445 FAx
(Alc No (978)532-2217
139 Lynnfield Street EMAIL :igoldman@crossagency.com
INSURER AFFORDING COVERAGE NAIC#
Peabody MA 01960 INSURERA.Main Street America Assur. Co 29939
INSURED INSURER 8:
JASON S HAYDEN INSURER C:
5 GUNSTOCK DR INSURER 0:
INSURER E;
KINGSTON NH 03848-3469 INSURER F:
COVERAGES CERTIFICATE NUMBER:CL1362487899 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
!NSR TYPE OF INSURANCE ADD R LEFF POLICY EXP
LTR PO
POLICY NUMBER ICY lODIY1fYY M IDDIY LIMITS
GENERAL LIABILITY EACH OCCURRENCE 5 1,000,OC
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
PREMISES occvne $ 500,OC
A CLAIMS-MADE a OCCUR 045992 /2/2013 /2/2014 MED EXP(AM one person) S 10,00
PERSONAL BADV INJURY $ 1,000,00
GENERAL AGGREGATE 5 2,000,00
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/0P AGG S 2,000,00
X POLICY PRO- Lor-
AUTOMOBILE
OCAUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
accident) S
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY Per accident) 5
AUTOS AUTOS ( )
NON-OWNED PROPERTY DAMAGE
HIRED AUTOS AUTOS Per acaderrl $
$
UMBRELLA LIAB OCCUR
EACH OCCURRENCE S
EXCESS UAB CLAIMS-MADE AGGREGATE S
DED RETENTION S $
WORKERS COMPENSATION WC STATU• OTH-
ANDEMPLOYERS'LIABILITY YIN „
ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT S
OFFICERIMEMBER EXCLUDED? N 1 A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If morn space is required)
A certificate of insurance has been requested from Hartford Insurance and will be forwarded under
separate cover by them.
Refer to policy for exclusionary endorsements and special provisions.
CERTIFICATE HOLDER CANCELLATION
ryan@norinanbuilders.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE: THEREOF, NOTICE WILL BE DELIVERED IN
M.R. Norman LLC ACCORDANCE WITH THE POLICY PROVISIONS.
Attn; Ryan Norman
63 Peaslee Crossing Road AUTHORIZED REPRESENTATIVE
Newton, NH 03856
Timothy Tramonte/LG4 u!ir:�` �"• .iia-rf+
ACORD 25(2010/05) O 1988-2010 ACORD CORPORATION. All rights reserved.
INS025)201005).01 Th.A(T1Rn no..,n+...i 1........_.._....:..a..__J....._..,__ _c Ai.---
NOTICE OF ASSIGNMENT
EMPLOYER: COMBO I.D. STATUS OF EMPLOYER
JASON S HAYDEN 000391451 Individual
5 GUNSTOCK DRIVE
KINGSTON, NH 03848 COVERAGE GROUP
0391451
Coverage under this assignment
The Waiver of Our Right to applies to Massachusetts
Recover from Others Endorsement operations only. For coverage
is available on Pool policies. outside of Massachusetts, contact
Contact your agent for details. the appropriate Pool or Plan for
that state.
INSURANCE COMPANY:
AGENT CRASS INSURANCE PEABODY (, HARTFORD UNDERWRITERS INS CO
OR LAUREN GOLDMAN
PRODUCER: 139 LYNNFIELD STREET Jonathan Schamberg
P 0 BOX 3556
PEABODY, MA 01960 ORLANDO, FL 32802-3556
x (800) 453-9843
AGENCY FEIN:263295403
CLASSIFICATION OF OPERATION CLASS ESTIMATED RATE ESTIMATED
CODE TOTAL ANNUAL PREMIUM
REMUNERATION
-------------------------------------------- ----- -------------- ---------- ----------
CARPENTRY-INSTALL OF CABINET WORK OR INT TRIM 5437 $5,000 5.23 $262
CARPENTRY NOC 5403 $0 9.61 $0
CARPENTRY-DETACHED ONE OR TWO FAMILY DWELLINGS 5645 $0 8.68 $0
CARPENTRY-DWELLINGS - THREE STORIES OR LESS 5651 $0 8.68 $0
EMPLOYERS LIABILITY 500/500/500 9807 $50
STANDARD PREMIUM $312
LOSS CONSTANT 0032 $50
EXPENSE CONSTANT 0900 $250
TERRORISM CHARGE 9740 $2
rOTAL POLICY MINIMUM PREMIUM $550
TOTAL ESTIMATED PREMIUM $614
DIA ASSESS. 4.2% $11
TOTAL EST. PREMIUM PLUS ASSESSMENT $625
NSTALLMENT BASIS: Annual DEPOSIT PREMIUM: $625
THIS IS NOT A BILL
;OMMENTS
-overage effective 12:01 AM on 06/22/13.
overage under this assignment is contingent upon compliance with the carrier's requests
:o complete the scheduled audit and payment of any additional audit premium.
3oncompliance will result in cancellation of current coverage.
ATE OF NOTICE: 06/24/13 PREPARED BY: Eve 1 yn Cobb
EXT 522
The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street- Boston, MA 02110
(617)439-9030• FAX(617)439-6055.www.wcribma.org
9 Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supers isor
License: CS-078189
JASON S HAM$
5 GUNSTOCK DIS
KINGSTON NH 83848f
)i jtik`' Expiration
12/13/2014
Commissioner
�e nzzrz�zriucneccl(f of C 1
.� Office of Consumer Affairs&Business Regulation
u --NOME IMPROVEMENT CONTRACTOR
registration: 174188 Type:
xpi ration: 117/2015 Individual
JASON S.HAYDEN
JASON HAYDEN
5 GUNSTOCK DR.
KINGSTON,NH 03848 Undersecretary
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M ii CEILING HEIGHT 95 1/2-96" m 7-BASE CABINET MODIFIED
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MHANGING HEIGHT 90" ----- �� A1; TO 12" DEEP/FULL HEIGHT
r a' -� 1 ; USE SFM 8 FOR SOFFIT DOORS WITH ADJUSTABLE
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All dimensions _size designations JANET MAGLIA This is an original design a
i given are subject to verification on JACKSON^ not be released or copied u